Manager of DRG Coding & Clinical Validation Audit

Elevance Health•Atlanta, IN

5d•Hybrid

About The Position

The Manager of DRG Coding Audit-Program/Project leads a high-performing team responsible for auditing inpatient medical records to ensure the accuracy and compliance of Diagnosis-Related Group (DRG) assignments. This role plays a critical part in identifying coding discrepancies and recoverable claim opportunities, and supporting regulatory integrity on behalf of the company and its clients. The role requires associates to be in-office 3 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered if candidates reside within a commuting distance from an office. Candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Requirements

Requires a BA/BS and minimum of 5 years experience in project/program management, process reengineering, organizational design, and/or implementation; or any combination of education and experience, which would provide an equivalent background.
Travels to worksite and other locations as necessary.

Nice To Haves

Preferred experience includes a minimum of 5-7 years of inpatient coding or DRG auditing experience, including 2-3 years in a leadership or supervisory capacity.
Experience working with ICD-9/10CM, MS-DRG and APR-DRG.
Broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, billing validation criteria and coding terminology preferred.

Responsibilities

Sets the strategic direction for audit methodologies, oversees team development, and ensures that audits meet the industry’s best practices and payer-specific requirements.
Collaborates cross-functionally with clinical, compliance, provider engagement, and data analytics teams to align audit insights with broader program goals.
Hires, trains, coaches, counsels, and evaluates performance of direct reports.
Analysis of audit trends, DRG shifts, and using financial outcomes to inform strategy.
Plans program/project scope and design.
Develops metrics and program/project reporting tools.
Analyzes variance to program/project plan.
Leads building of documentation to support business objectives and ensure consistency.
Responsible for championing local stakeholders and tactical decision-makers.
Suggests and develops high quality, high value concept and or process improvement and efficiency recommendations.
Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions.